I'm not taking those staples out

[Darkfield]

I have a pt who has been in our ICU for over a month now. Uncontrolled diabetes, severe respiratory distress. On the vent for about a month, he's since been trached. Can't wean him down from 100% FIO2. Five chest tubes. Around three weeks ago, he had a thoractomy. He has staples on his back on the left side. They are growing into his skin. I can physically remove staples, but I am not allowed to at my facility. Today, I caught the thoraccic resident as he was doing his speedy rounds and handed him a staple remover. This is why he wouldn't remove them:

-He's going to die anyway, and staples are the least of his problems. Did you see his chest xray? Exactly. If we remove those staples, all the pus from his lungs will leak out all over. Anyway, last time he was turned (two days ago, according to the doc), a chest tube kinked off and he blew another pneumo.

Me: We bathed him three hours ago, and he did fine. Full turn and everything. No pneumo. Besides, you can't just not take care of a patient because he is going to die. His butt gets dirty, and we clean that even though it won't save his life.

Him: no, He is too unstable to turn. If you can get his O2 down to 80, I'll remove the staples.

WTH? Does he think we don't turn pts? And this is the story of the MICU, 20% of our pts won't live, and we know it, but we take stellar care of them. This pt, we've done a great job with. Besides his lungs, he is so much better then when he came in. He was morbidly obese, and now he's just obese. We've healed the extensive ulcers on his leg, and nearly fixed the abcess in his armpit with our great nursing care...he'll probably go septic again from the staples. What do you guys think?

[suanna]

You can't remove staples in a Critical Care area?- WOW- I'd imagine pulling chest tubes, D/Cing swans and the like would be forign territory as well. You could do your patients and your docs a great favor if you could make a list of the proceedures you are forbidden to do that are in the scope of practice of a nurse and present the option of nursing assuming those duties as soon as the docs are comfortable with relinquishing thier tasks. As busy as a ICU practice can be, I can't imagine there being much resistance to nursing taking over those tasks you are qualified to do with approval of the physician staff.

[caroladybelle, BSN, RN]

I am surprised that you are not permitted to remove staples.

And second, with regard to the Resident, what MD would want to leave staples to hold the purulent drainage IN!!!!!! Generally, most MDs want to allow that material to drain out, to reduce infection and improve healing. However the resident indicates from the lung. I am wondering why the wound would be open that far interiorly as there should be internal self absorbing sutures underlying, I would think. And that the team would have placed a drain to pull off the purulence.

There is also possibly a fear that d/t the obesity and/or wt chg, that there may be more pull on the tissues and it takes more time to heal a wound, especially a deep one.

While I am not familiar with this specific wound and I can understand the resident may be frustrated, this does not sound right. Have you made the Attending aware or your infection control nurse.

[ckh23, BSN, RN]

I'm gonna raise the BS flag here. I would again reiterate why the staples should come out and if need be go over his head. Sometimes just the threat of a call to their attending is enough to at least seriously think about why he should or should not take the staples out. I'm sure the attending might be interested in knowing is attitude toward certain patients about not caring for them properly because they probably will die.

I have found attendings are usually in the dark when it comes to certain things because you know this resident isn't reporting back that Nursing thinks it's time for the staples to come out.

Just my humble opinion.

[Darkfield]

We aren't allowed to do certain things because it is a teaching hospital, I think, and the residents need to learn to do everything and think of everything. With things like taking out staples, I think it is a nursing issue rather than a doc one.

I could go to the MICU attending about the staples, but depending on who it is, they might not care. The patient is going to die anyway, but it just irks me that we would drop our standards because of that.